■ The expansion is off limits to immigrants in the U.S. illegally and to legal residents who have been in the country less than five years.

Washington Even if they're legal residents in a state that expands Medicaid, many poor immigrants still are not eligible for coverage.

The Affordable Care Act provision calling for states to expand their program eligibility up to an effective rate of 138% of poverty has been seen as an important coverage tool for low-income populations next year. But a Robert Wood Johnson Foundation report released March 18 estimates that about 3.5 million legal immigrants or those in the country illegally, who make up about 17% of all low-income, nonelderly uninsured adults, won't be able to get coverage under this provision.

Immigrants who are in the country illegally are excluded from expanded coverage automatically. Those who recently became legal residents are not going to be eligible right away, as they are barred from Medicaid coverage for the first five years after they become permanent U.S. residents. Most Americans assume the ACA covers everyone, “but what this report shows is that there are still folks living in our country who don't have health insurance,” said Jeffrey Cain, MD, president of the American Academy of Family Physicians. Providing these populations with some form of coverage would give them access to primary care and save money for the health care system by preventing unnecessary, uncompensated trips to emergency departments, he said.

The report gives the first state-specific estimates on the number of low-income uninsured adults who will not get Medicaid coverage under the expansion because of their immigration status. The research was conducted by the State Health Access Data Assistance Center, a program of the Robert Wood Johnson Foundation and part of the University of Minnesota's School of Public Health.

Andy Hyman, senior program officer and director of the foundation's coverage team, suggested that states may want to devise safety-net strategies “in conjunction with a national response to meet the needs of these underserved populations that will likely remain uninsured” after the ACA's major coverage provisions go into effect in 2014.

But some physicians questioned whether policymakers would take notice. “These are the people that nobody cares about. They otherwise don't exist” even though they're a part of the nation's work force, said Thomas C. Bent, MD. He's medical director and chief operating officer of Laguna Beach Community Clinic in Orange County, Calif., and is the past president of the California Academy of Family Physicians.

Immigrants often avoid seeking care

Of the 5,000 patients the Laguna Beach clinic treats, 45% are Hispanic. “We see mostly uninsured or underinsured people, but we do not track who is legal or not,” Dr. Bent said. Getting them the care they need is a challenge now, he added.

In the area where Dr. Bent practices, some care options outside of Medicaid are available to immigrants, including a county-based program that provides medical services for legal residents of Orange County. There's also a reproductive health services program that provides care regardless of immigration status, Dr. Bent said. One problem is that immigrants often are too hesitant to apply for resources for which they might be eligible.

“Patients are worried that this program will trigger some sort of investigation that will get them deported, or if they're in the process of trying to get legal status, they're paranoid that any application for benefits could scotch their ability to get paperwork and get their legal status,” he said.

Cost concerns are another factor. Mark Dressner, MD, president-elect of the California Academy of Family Physicians, practices at the Children's Clinic, a federally qualified health center in Long Beach, Calif. He said his immigrant patients may show up at the clinic for an appointment and then leave “because they do not want to be billed even a nominal fee, like $5 a month. It always saddens me greatly that they will go without their necessary diabetes or asthma medications,” he said.

Dr. Dressner said he applauded the ACA for providing for citizens, but “I worry very much about those flying under the radar.” In his personal view, “everyone needs health care, and it doesn't matter if you're here legally or illegally.” Dr. Dressner said he tries to encourage his patients who are legal residents to become U.S. citizens, so they can get access to health care more easily.

It may get to a point where community clinics that serve as the safety net for these patients see their funding dry up, Dr. Dressner said. As more people go into Medicaid and more of the federal government's health care money is directed toward financing the care of the newly enrolled, questions remain as to whether there are going to be major cuts for existing federally qualified health centers such as the Children's Clinic, he said. “I think that will be coming down the pike and that the immigrants are going to lose.”

The American Medical Association has several policies supporting the care of immigrant populations. For example, it opposes any actions that would punish doctors for giving care to immigrants who are in the U.S. illegally.

ADDITIONAL INFORMATION

Big numbers of immigrant U.S. residents won't get coverage

The Robert Wood Johnson Foundation estimates that about 3.5 million poor, uninsured immigrants — those who are in the country illegally and legal residents who haven't been in the U.S. long enough — won't be covered under the Affordable Care Act's Medicaid expansion provision. The situation will be most evident in states such as Nevada, in which these immigrants make up a large percentage of the uninsured population.

State

Low-income, uninsured nonelderly adults (in thousands)

Portion who are immigrants

Alabama

358

5%

Arizona

447

31%

Arkansas

249

6%

California

2,943

26%

Colorado

321

20%

Connecticut

125

20%

Delaware

35

22%

Florida

1,619

16%

Georgia

894

20%

Hawaii

45

10%

Idaho

111

9%

Illinois

839

19%

Indiana

403

7%

Iowa

111

9%

Kansas

157

13%

Kentucky

343

5%

Louisiana

361

4%

Maryland

266

19%

Massachusetts

109

22%

Michigan

645

5%

Minnesota

166

10%

Mississippi

252

3%

Missouri

371

4%

Nebraska

92

12%

Nevada

224

34%

New Jersey

428

22%

New Mexico

174

13%

New York

930

17%

North Carolina

721

20%

Ohio

693

4%

Oklahoma

305

9%

Oregon

290

13%

Pennsylvania

530

6%

Rhode Island

49

23%

South Carolina

366

8%

Tennessee

459

8%

Texas

2,514

26%

Utah

152

14%

Virginia

405

12%

Washington

370

13%

Wisconsin

227

10%

Note: Estimates of some states were not included because study authors determined that their relative standard errors exceeded 30%.

Source: State Estimates of the Low-income Uninsured Not Eligible for the ACA Medicaid Expansion, Robert Wood Johnson Foundation and State Health Access Data Assistance Center, March 18 (link)